Apply for Discretionary Test and Trace Support Payments

Title:

If other is chosen, state title:

First name:

Last name:

Date of Birth:

Address:

Postcode:

Phone number:

Email address:

Who are you completing this application for?

Yourself - you have to self-isolate
Yourself - your child has to self-isolate*
On behalf of someone else

*If you selected: ‘Yourself - my child has to self-isolate’ please answer the following questions about your child.

Otherwise, skip to 'Name of applicant.'

Your child's name:

Your child's age:

Your child's main address:

Your child’s education or care setting and year group:

Email address and phone number for this care setting:

Your child’s first day of self-isolation:

Does your child have an education, health and care plan?

Yes
No

Please provide evidence of at least one of the following:

- Your child’s 8 digit NHS track and Trace ID number
- Communication from your child’s education or childcare setting confirming that they have to self-isolate
- A screenshot of a young person’s NHS COVID-19 App notification telling them to self-isolate and evidence that the young person has an education, health and care plan

All self-declared information you provide about your child will be checked with their education or care setting

Upload evidence to confirm that your child needs to self-isolate:

Name of applicant:

Address of applicant:

Provide your 8 digit Test and Trace ID number:

Provide the start date of your isolation period:

Provide the end date of your isolation period:

Are you:

Employed
Self emplyed

Employer name:

Employer's address:

Employer's contact number:

What is the nature of your job?

Are you able to work from home during your isolation period?

Yes
No

Will you have a reduction in earned income?

Yes
No

Are you currently in receipt of furlough pay?:

Yes
No

Have you travelled abroad within the last 3 months?

Yes
No

Are you in receipt of the Covid-19 Self-Employment Income Support Scheme grant from HMRC?:

Yes
No

Is there any other income coming into you household? (e.g. partner’s wages, pensions, income from property)

Yes
No

If 'Yes' please provide details and amounts:

Please provide your latest self-employed accounts or HMRC tax return. If self-employed less than 1 year please provide evidence of registration with HMRC.

If you are self employed provide proof of your self employment status:

If you are employed provide evidence that you will not receive full occupational sick pay:

What is the total value of all capital held in accounts in your sole name or joint accounts?

(Use 50 percent of the balance of any joint accounts.) This total should include all money in any bank / building society accounts, ISAs, shares, bonds, etc.

Provide your National Insurance Number:

Please provide the following detail of the bank account you wish the payment to go into. (The bank account must be in the name of the applicant)

Bank account name:

Account number:

Sort Code:

Upload your evidence documents one by one. If you are employed this should also include proof of employment / loss of earned income i.e. your most recent wage slip(s) or a letter from your employer.

We will also require bank statements for all accounts you are named on, covering the last month, as well as evidence of any other capital you hold ( bonds, shares etc.) All statements should include the name of the account holder and the account number and sort code.

Upload evidence documents:

Under the Equality Act we have a responsibility to collect details of our customer groups. The information gathered is used to help us ensure that all protected groups are fairly treated in all our policies and procedures ensuring fair and equal access to all.

The information you give is confidential and will only be used to provide our services to everyone.

We would appreciate your help by completing the form below. However you do not have to fill it in and will not affect your claim in any way.

How old are you?

What sex / gender to you identify as?

Have you undertaken any form of sex / gender reassignment?

Are you currently pregnant or have you given birth within the last year?

Do you have a disability, long-term illness, or health condition?

Which ethnicity best describes you?

Which of the following terms best describes your sexual orientation?

What do you consider your religion or belief to be?

Declaration

I confirm that the information is true and accurate. I agree to self-isolate for the required period and understand that if I fail to self- isolate or do not have a reduction of income for the self- isolation period I will be required to pay the funds back.

I agree that if my child is not required to self-isolate I will be required to pay the funds back.

The Council relies on your consent to access your records contained in the NHS Test and Trace Data System (CTAS) for the purposes of confirming your eligibility for this scheme of payment. You can find more information on CTAS in the Privacy Notice on the NHS website.

Your data will not be shared with other entities outside of the Council for any purpose. You may withdraw your consent at any time by calling us on 0118 974 6000. If you do withdraw your consent, you will no longer be entitled to the payments under this scheme.

For information about how we will process the information gathered on the form, read our privacy statement.

I agree to the above declaration:

Tick box to agree

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